International collaboration to improve physiotherapists’ training, Viet Nam

Abstract Problem Like most low- and middle-income countries, Viet Nam has a scarcity of rehabilitation professionals and lacks training programmes that meet international standards. Approach In 2018, four Vietnamese medical universities, the Université Catholique de Louvain, the Université Libre de Bruxelles, the Humanity & Inclusion charity and World Physiotherapy agreed to collaborate on strengthening pre-service education for physiotherapists in the country. Local setting Viet Nam has a favourable environment for nurturing rehabilitation services and education: development funds have been available; government investment is increasing; and rehabilitation education has existed for many decades. Relevant changes The collaboration resulted in the establishment of: (i) a 4-year, competency-based, entry-level curriculum for physiotherapists (bachelor’s degree); (ii) opportunities for continuing professional development; (iii) a 2-year master’s programme for physiotherapy lecturers and clinical supervisors; and (iv) a national physiotherapy association. In addition, four students were supported in studying for PhD degrees. Strong collaboration and comprehensive and complementary interventions have laid the foundations for sustainable, high-quality, educational programmes for physiotherapists, which will improve access to, and the standard of, rehabilitation services in Viet Nam, thereby leading to better patient outcomes. Lessons learnt Curricula for entry-level physiotherapy programmes should be competency-based, be actively managed by national educators and meet international standards while being responsive to local priorities. To strengthen the rehabilitation workforce, educators involved in teaching and supervising training programmes should have the skills and knowledge required. A national professional physiotherapy association should be established to provide continuing professional development for physiotherapists and to take part in international collaborations.


Introduction
Around 7% of the Vietnamese population has a disability, 1 which corresponds to more than 6 million individuals. In addition, the number of people with noncommunicable diseases in the country is rising, 2 the population is ageing rapidly and Viet Nam has a road traffic crash rate above the average for South-East Asia. 3, 4 As a result, the need for rehabilitation services is increasing. 5 In 2019, a systematic assessment of rehabilitation in Viet Nam found that most health facilities were equipped to provide rehabilitation services: the proportion ranged from 75% at the district level to 100% at the central level (unpublished data, Viet Nam Ministry of Health, 2020). However, only 7200 individuals had a pre-service training qualification in rehabilitation; the majority were physiotherapists with 2-year diploma certificates. Other qualified professionals included prosthetists, orthotists, speech language therapists and occupational therapists. In addition, a range of other health workers had undertaken short orientation courses in rehabilitation of 3 to 12 months' duration. Overall, the quality of health and rehabilitation services provided across Viet Nam and patient outcomes were variable because of the low number of health-care professionals for the population size and the short duration of training.
Shortages of rehabilitation professionals, health-care workers with a relatively low level of skills and knowledge, and the inequitable distribution of these workers have been identified as major barriers to accessing rehabilitation services worldwide, particularly in low-and middle-income countries. 6 Both pre-service training and continuing professional development are crucial for ensuring high-quality services. 7 A 2017 report from the World Health Organization, entitled Rehabilitation 2030: a call for action, 8 identified building an adequate, well-trained and multi-occupation rehabilitation workforce as central to strengthening rehabilitation in the health system. When faced with rehabilitation workforce shortages, organizations and individuals aiming to strengthen services and develop pre-service or initial training are usually presented with two options: (i) develop or strengthen highquality, university-level, educational programmes aligned with international standards and requirements and having a long-term vision; 9 or (ii) address urgent needs through short courses, such as orientation courses for other health-care Problem Like most low-and middle-income countries, Viet Nam has a scarcity of rehabilitation professionals and lacks training programmes that meet international standards. Approach In 2018, four Vietnamese medical universities, the Université Catholique de Louvain, the Université Libre de Bruxelles, the Humanity & Inclusion charity and World Physiotherapy agreed to collaborate on strengthening pre-service education for physiotherapists in the country. Local setting Viet Nam has a favourable environment for nurturing rehabilitation services and education: development funds have been available; government investment is increasing; and rehabilitation education has existed for many decades. Relevant changes The collaboration resulted in the establishment of: (i) a 4-year, competency-based, entry-level curriculum for physiotherapists (bachelor's degree); (ii) opportunities for continuing professional development; (iii) a 2-year master's programme for physiotherapy lecturers and clinical supervisors; and (iv) a national physiotherapy association. In addition, four students were supported in studying for PhD degrees. Strong collaboration and comprehensive and complementary interventions have laid the foundations for sustainable, high-quality, educational programmes for physiotherapists, which will improve access to, and the standard of, rehabilitation services in Viet Nam, thereby leading to better patient outcomes. Lessons learnt Curricula for entry-level physiotherapy programmes should be competency-based, be actively managed by national educators and meet international standards while being responsive to local priorities. To strengthen the rehabilitation workforce, educators involved in teaching and supervising training programmes should have the skills and knowledge required. A national professional physiotherapy association should be established to provide continuing professional development for physiotherapists and to take part in international collaborations.
Lessons from the field Strengthening rehabilitation, Viet Nam Didier Demey et al.
providers (e.g. nurses, traditional doctors or community health workers), with the objective of enabling task-shifting. Although both approaches can lead to successful outcomes, 10 the choice usually depends on the context and opportunities locally; funding, the time available, and local resources and expertise. These factors often make it less attractive to choose the first option even if it would be expected to have a more sustainable long-term impact. 6,11 Here we describe how an international collaboration focused on the first option to strengthen pre-service education for physiotherapy with the goal of improving rehabilitation workforce and access to rehabilitation services in Viet Nam.

Local setting
Over recent decades, rehabilitation services in Viet Nam have developed rapidly thanks to a favourable environment. First, international development funds have been available, which has enabled a variety of actors to support rehabilitation services. For example, since 1987 the United States Agency for International Development has contributed over 100 million United States dollars (US$) to support people with disabilities. 12 Second, rehabilitation education (mostly for physiotherapists, prosthetists and orthotists) has existed in the country for almost 50 years. Third, a rehabilitation professional association (the Viet Nam Rehabilitation Association) was established in 1991 and had around 4000 members in 2022. Fourth, steady economic growth has enabled government investment in health and rehabilitation to increase: health-care expenditure in Viet Nam accounted for 7.5% of the country's gross domestic product in 2017 and social health insurance covers an array of rehabilitation services. 13,14 Finally, local authorities have developed several rehabilitation policy documents (e.g. the National Plan for Rehabilitation Services Development), 15 which provide a solid foundation for building rehabilitation services. Still, much remains to be done, particularly with regard to workforce development and education.

Approach
In Viet Nam, the disability charity Humanity & Inclusion, the Univer-sité Catholique de Louvain, the Université Libre de Bruxelles and World Physiotherapy collaborated with four Vietnamese medical universities (Hai Duong Medical Technology University, Da Nang University of Medical Technology and Pharmacy, the University of Medicine and Pharmacy at Ho Chi Minh City and Hong Bang International University) and the newly formed Viet Nam Physical Therapy Association to increase the capacities of the rehabilitation workforce by strengthening university-level and competency-based pre-service educational programmes for physiotherapists. At the same time, other organizations were involved in providing short courses.
In 2016, Humanity & Inclusion and World Physiotherapy undertook a gap analysis of entry-level physiotherapy educational programmes at the four Vietnamese medical universities (Humanity & Inclusion and World Physiotherapy, unpublished data, 2017). Their main findings included the following: (i) existing physiotherapy curricula were not aligned with international standards and were not evidence-based; (ii) clinical placements did not promote independent clinical reasoning; and (iii) students were supervised by clinicians who lacked skills in contemporary patient management. On the basis of these findings, World Physiotherapy recommended: (i) developing a new national physiotherapy curriculum based on a World Physiotherapy education framework that is customized to meet the social, cultural and national priorities of Viet Nam; 16 (ii) helping lecturers and clinical supervisors attain higher degrees that will enable them to deliver the curriculum and provide high-quality leadership; (iii) developing continuing professional education for physiotherapists, particularly those working in academia and clinical practice, to enable them to deliver the curriculum and provide clinical care to contemporary standards; (iv) developing national physiotherapy standards; and (v) supporting the establishment of a national physiotherapy association.
At t he t ime, t he Université Catholique de Louvain was already actively supporting physiotherapists in Viet Nam by providing staff to teach regular, short, training courses for physiotherapists and lecturers at the University of Medicine and Pharmacy at Ho Chi Minh City.
The Viet Nam Physical Therapy Association was formally recognized as a member of World Physiotherapy in 2021. Meanwhile, the four Vietnamese medical universities, the Viet Nam Physical Therapy Association, World Physiotherapy and Humanity & Inclusion (with the support of the Vietnamese health ministry and education and training ministry and with funding from the United States Agency for International Development and the Australian Physiotherapy Association) started to develop national physiotherapist competency standards and a national curriculum framework for physiotherapists (Fig. 1). Then, World Physiotherapy mentors worked with each of the four universities to develop their own curricula, which were based on agreed competency thresholds and international standards. The curriculum development process was collaborative and fully involved university staff.
To address weaknesses in the educational level of staff involved in teaching physiotherapy, the Université Catholique de Louvain and the Université Libre de Bruxelles secured funds from the ARES federation 17 to develop and implement a 2-year master's degree programme that prioritized physiotherapy lecturers and student clinical supervisors. The programme was jointly developed and implemented by representatives of the Université Catholique de Louvain and the University of Medicine and Pharmacy at Ho Chi Minh City (with the support of World Physiotherapy and Humanity & Inclusion) and was approved by local academic authorities. In addition, funding was secured to enable four physiotherapy teachers from the University of Medicine and Pharmacy at Ho Chi Minh City to complete PhD degrees in Belgium. The Université Catholique de Louvain, Humanity & Inclusion and World Physiotherapy have maintained their involvement in developing continuing professional development courses for lecturers and clinical supervisors as well as for the wider physiotherapy profession.
Due to the coronavirus disease 2019 pandemic, from March 2020, the country closed its borders for more than 18 months. Teachers and consultants were prevented from entering Viet Nam as planned. To maintain momentum, hybrid curriculum development workshops were organized with Vietnamese Lessons from the field Strengthening rehabilitation, Viet Nam Didier Demey et al.
teachers gathering at one university and consultants available online. Mentoring for individual universities was provided remotely. The master's programme was adapted so that teaching could be temporarily provided online. When Viet Nam reopened its borders, travel and onsite workshops recommenced.

Relevant changes
By early 2022, our combined interventions in Viet Nam had enabled collaborators to achieve the following core results. First, national competency standards for physiotherapists were developed and will soon be validated by the health ministry. Second, the Viet Nam Physical Therapy Association has 753 members and is one of the fastest growing World Physiotherapy member organizations. Third, the 4-year bachelor's degree curricula have been revised for all four partner universities and have been reshaped to align with new competencies. These were due to be introduced in the 2022 to 2023 academic year. Fourth, the first cohort on the physiotherapist master's programme started in late 2020 -16 participants were expected to graduate in November 2022. A second cohort was planned to start shortly afterwards. Finally, three of the four PhD candidates from the University of Medicine and Pharmacy at Ho Chi Minh City had started work on their theses. The fourth candidate was due to start his thesis in late 2022.

Lessons learnt
The three main lessons learnt during the project are summarized in Box 1. By ensuring these skills are core competencies to be acquired in bachelor's or master's degree programmes, our intervention is expected to have a long-lasting, positive impact on the quality of rehabilitation services and on patient outcomes. Although significant investments were made at the start of our collaborative project (e.g. the United States Agency for International Development invested about US$ 150 000 in the education gap analysis and bachelor's programme review, the ARES federation invested about US$ 500 000 to support the master's and PhD programmes, and the Australian Physiotherapy Association invested US$ 30 000 to support the development of national competencies standards), our approach guarantees long-term sustainability. First, bachelor's degree programmes have been revised with the participation of Vietnamese organizations, thereby ensuring local ownership. Second, universities and national authorities in Viet Nam are in the process of approving these new programmes. Third, the competence of existing teachers and clinical supervisors is being strengthened by participation in master's or PhD programmes, which will ultimately enable them to assume responsibility for local programme administration.
We acknowledge that Viet Nam benefits from an environment that favours the nurturing of rehabilitation services and education and that many low-income and, even, middle-income countries may not have a similar advantage. Nevertheless, the collaborative approach we developed and implemented in Viet Nam and lessons learnt could be applied successfully in other countries.  Competing interests: None declared.

Box 1. Summary of main lessons learnt
• Curricula for entry-level physiotherapy programmes should be competency-based and developed with the participation of national and international academics, and the national rehabilitation professional association should both meet international standards and be responsive to local priorities. • To be effective, efforts to strengthen the rehabilitation workforce should focus on the curriculum for initial physiotherapy training. In addition, the capacities of teachers, lecturers and clinical supervisors should be improved to enable them to implement an up-to-date curriculum. • Building a national professional physiotherapy association is important for achieving national and international recognition of the profession and for ensuring access to continuing professional development programmes.
Lessons from the field